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Abstract

Partner violence is linked to cervical cancer and other gynaecological conditions. However, results of current research into associations between partner violence and cervical cancer screening have been inconclusive. Therefore, the current research investigates the association between partner violence and inadequate cervical cancer screening. Participants were 7312 women aged 45-50 years who responded to the Australian Longitudinal Study on Women's Health population-based surveys in 1996 and 2004. The women self-reported frequency of Pap smears via mailed questionnaire. Women who had experienced partner violence at least eight years earlier, compared with those who had not, were more likely to report current inadequate screening (OR: 1.42, 95%CI: 1.21; 1.66). After adjusting for known barriers to preventive screening (education, income management, marital status, general practitioner visits, chronic conditions) and depression, partner violence was independently associated with inadequate Pap tests (OR: 1.20, 95%CI: 1.01; 1.42). This association was no longer significant once access to a GP of choice was added to the model (OR: 1.18, 95%CI: 0.99; 1.40). The significance of this study lies not just in confirming a negative relationship between cervical cancer screening and partner violence, but in suggesting that good access to a physician of choice appears to significantly decrease this negative relationship.
Inadequate cervical cancer screening among mid-aged Australian women who have
experienced partner violence
Deborah Loxton
a,
, Jennifer Powers
a
, Margot Schoeld
b
, Rafat Hussain
c
, Stacey Hosking
a
a
Research Centre for Gender, Health and Ageing, University of Newcastle, Australia
b
La Trobe University, Victoria, Australia
c
School of Health and School of Rural Medicine, University of New England, Australia
abstractarticle info
Available online 5 November 2008
Keywords:
Cancer screening
Intimate partner violence
Domestic violence
Pap test
Cervical cancer
Objectives. Partner violence is linked to cervical cancer and other gynaecological conditions. However,
results of current research into associations between partner violence and cervical cancer screening have
been inconclusive. Therefore, the current research investigates the association between partner violence and
inadequate cervical cancer screening.
Methods. Participants were 7312 women aged 4550 years who responded to the Australian Longitudinal
Study on Women's Health population-based surveys in 1996 and 2004. The women self-reported frequency
of Pap smears via mailed questionnaire.
Results. Women who had experienced partner violence at least eight years earlier, compared with those
who had not, were more likely to report current inadequate screening (OR: 1.42, 95%CI: 1.21; 1.66). After
adjusting for known barriers to preventive screening (education, income management, marital status,
general practitioner visits, chronic conditions) and depression, partner violence was independently
associated with inadequate Pap tests (OR: 1.20, 95%CI: 1.01; 1.42). This association was no longer signicant
once access to a GP of choice was added to the model (OR: 1.18, 95%CI: 0.99; 1.40).
Conclusions. The signicance of this study lies not just in conrming a negative relationship between
cervical cancer screening and partner violence, but in suggesting that good access to a physician of choice
appears to signicantly decrease this negative relationship.
© 2008 Elsevier Inc. All rights reserved.
Introduction
Cervical cancer is a signicant cause of morbidity and mortality
in women (World Health Organisation, 2003; American Cancer
Society, 2007). Screening procedures with good sensitivity and
specicity such as Pap tests are widely available for early detection
of cervical cancer. Current guidelines recommend Pap tests at least
every three years in the USA (American Cancer Society, 2008), and
screening at two yearly intervals in Australia (Australian Institute of
Health and Welfare, 2008). The uptake of cervical cancer screening
through Pap tests is relatively high, with screening rates of 82% for
American women aged 25 and older in 2000 (American Cancer
Society, 2008), and 61% of Australian women aged 20 to 69
(Australian Institute of Health and Welfare, 2008). Nevertheless,
overall gures tend to mask the differentials in uptake of cervical
screening, with studies showing the rates to be considerably lower
among some groups of women (Harris, 2000; Lockwood-Rayer-
mann, 2004; Lofters et al., 2007).
It is essential to determine whether those at high risk are being
screened at optimal rates, and to identify potential barriers to
screening. For example, barriers to cervical cancer screening include
marital status, low socio-economic status and limited education, as
well as chronic conditions such as diabetes, depression and obesity
(Wee et al., 2000; Savage and Clarke, 2001; Weinrab et al., 2002;
Hewitt et al., 2004; Pirraglia et al., 2004; Ostbye et al., 2005). There are
indications that intimate partner violence could be associated with
inadequate preventive cervical cancer screening. For instance, a
history of violence in women with cervical cancer has been associated
with advanced stage of cancer at diagnosis (Modesitt et al., 2006). The
current paper examines partner violence as a potential barrier to
adequate screening for cervical cancer.
Around 20% of women in western countries will experience
partner violence in their lifetime (Tjaden and Thoennes, 20 00;
Australian Bureau of Statistics, 2006). This is a serious public health
issue in its own right (World Health Organization, 2002). Research has
demonstrated a consistent association worldwide between partner
violence and a wide range of health problems including cardiovascular
disorders, gastrointestinal symptoms and illnesses, and increased
reporting of aches, pains and fatigue (McCauley et al., 1995; Coker
et al., 2000; Kernic et al., 2000; Loxton et al., 2006). Partner violence
Preventive Medicine 48 (2009) 184188
Corresponding author.
E-mail address: Deborah.Loxton@newcastle.edu.au (D. Loxton).
0091-7435/$ see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2008.10.019
Contents lists available at ScienceDirect
Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed
has also been linked to increased risk of cervical cancer and other
gynaecological problems (Campbell et al., 2000; Loxton et al., 2006).
Furthermore, women who have lived with a violent partner have a
higher risk than other women of sexually transmitted infections and
should therefore be considered at higher risk for cervical cancer
(Plichta and Abraham,1996; Augenbraun et al., 2001; Taft et al., 2004).
Consequently, it is important to know whether women who have
experienced partner violence are engaging in adequate preventive
screening behaviour. However, there has been limited research in this
area. A US study that found women (aged 1854) who had
experienced physical or sexual partner violence were more likely to
undergo regular Pap smear screening (Lemon et al., 2002). Similar
results were found in an Australian study of a representative sample of
1823 year old women (Taft et al., 2004). However, the ndings
mentioned earlier concerning late stage diagnosis of cervical cancer
among women who had experienced violence (Modesitt et al., 2006)
suggest that screening among women who have experienced partner
violence might be less than optimal.
Identication of risk factors for inadequate screening for cervical
cancer allows us to develop effective screening recommendations to
address those risk factors. For example, age and family history have
well known associations with cervical cancer, and have been
incorporated into screening recommendations (Australian Institute
of Health and Welfare, 2008). The current study examined the
relationship between partner violence and preventive screening
using a large representative community based sample of mid-aged
Australian women, and adjusted for previously identied barriers
(marital status, socio-economic status, chronic conditions) to pre-
ventive screening in order to determine the relationships between
partner violence and Pap testing. It also examined the impact of
perceived access to a GP of choice on the relationship between partner
violence and cervical cancer screening after controlling for known
confounders.
Methods
The Australian Longitudinal Study on Women's Health (ALSWH) is
a prospective study of factors affecting the health and well-being of
three cohorts of women. The womenwere randomly selected from the
national Medicare database that includes all permanent residents of
Australia, with over-sampling in rural and remote areas. This paper
focuses on the mid-aged women who were 4550 years in 1996. The
consent rate for participation in this 20 year study was 54% and
comparison with the 1996 Census indicates the respondents were
reasonably representative of women of this age in the general
population, but with some over-representation of women with
tertiary education. Further details of the recruitment methods and
response rates have been described elsewhere (Brown et al., 1998; Lee
et al., 2005).
Participants
Of the 13,716 women who responded to Survey 1 (S1) in 1996,
10,905 women (80%) respondedto Survey 4 (S4) in 2004,1052 women
could not be contacted, 886 women were contacted but did not return
S4, 635 women had withdrawn from the project, 203 women were
deceased and 35 women were unable to ll in S4 due to incapacity.
After exclusion of 3273 women who had had a hysterectomy, 249
women who had experienced partner violence since S1 and 71
women who had missing data for partner violence at S1 or S4, 7312
women were included in the analyses.
Measures
Mailed questionnaires were used to collect data about health
factors, health service use, health behaviours and socio-demographic
factors. Surrogate measures of socio-economic status included the
highest educational qualication achieved (S1) and whether the
women had difculty managing on their available income (S4).
Residential postcode was used to categorise area of residence as
urban, rural or remote (S1).
Partner violence
Have you ever been in a violent relationship with a partner/spouse
was asked in S1 and S4. Women were also asked if they currently live
with a partner/spouse (S4).
Health status
Women were asked: In the past three years, have you been diagnosed
with or treated for: diabetes, heart disease, stroke, thrombosis or
breast, cervical or bowel cancer. A woman was considered to have a
chronic physical condition if she gave an afrmative response to any of
these conditions (S4).
Depression
The 10 item Center for Epidemiological Studies Depression scale
was included in S4. The recommended cut-off score of 10 or more was
used to indicate depression (Andresen et al., 1994).
Health service use
At S4, women reported on the number of times they had consulted
a general practitioner (GP) in the last year (02, 36, 7 or more visits).
Women were asked to rate their access to health service providers. A
woman was considered to have good GP access if she rated her ease of
seeing the GP of her choice as excellent, very good or good (S4).
Preventive screening
Cervical screening was considered adequate for women who
reported having had a Pap test in the past two years (S4). Women were
also asked if a doctor had checked their blood pressure and cholesterol
in the last three years (S4).
Statistical analyses
Various characteristics are associated with Pap screening and
partner violence: health service use, physical conditions, depression
and socio-demographic factors such as education, ability to manage
on available income, marital status, area of residence and age.
Likelihood-ratio chi-square statistics were used to test whether
these characteristics were associated with partner violence. Two-
tailed tests with pvalues less than or equal to 0.05 were considered
statistically signicant.
Separate multivariable logistic regression models were built to
examine the relationships between partner violence at S1 and
subsequent inadequacy of Pap smears at S4. Women who had not
experienced partner violence at S1 were the reference group. Firstly,
odds ratios were estimated from models that included only partner
violence as the independent variable. Secondly the models were
adjusted for socio-demographic and health factors. Thirdly GP access
was added to the adjusted models to determine whether this factor
explained the difference in screening between womenwho had or had
not experienced partner violence. In addition, all models were
adjusted for area of residence to allow for the purposeful over-
sampling of women in rural and remote areas at S1. Due to the small
age range (5358 years at S4), models were not adjusted for age. All
analyses were performed with SAS statistical software, version 9.1
(SAS Institute Inc, 1999).
Results
At S1, 15% of 13,716 women had experienced partner violence
compared with 13% of 10,905 women at S4. Women who had
185D. Loxton et al. / Preventive Medicine 48 (2009) 184188
experienced partner violence were more likely to be uncontactable
(28%) or incapable (eg dementia, stroke) or deceased (21%) than
respondents (15%) at S4. Of the 7312 women included in the analyses,
13% had experienced partner violence by S1. Table 1 shows
associations between partner violence and socio-demographic char-
acteristics. Women who had experienced partner violence had more
difculty managing on their available income (51% versus 33%) and
were less likely to be living with a partner (59% versus 81%) than
women who had never experienced partner violence.
Partner violence was signicantly associated with more GP visits
in the previous year, worse access to a GP of choice, the presence of
a chronic physical condition and depression (Table 2). Women who
had experienced partner violence were equally likely to have had
their blood pressure and cholesterol checked relative to other
women.
Both unadjusted and adjusted odds ratios (OR) for inadequacy of
cervical cancer screening are presented in Table 3. Higher odds of
inadequate Pap tests were associated with previous partner violence
(unadjusted OR 1.42, 95%CI 1.21, 1.66). After adjusting for known
confounders, the odds ratio for inadequate Pap testing was still
signicant (Table 3). However when GP access was added to the
adjusted model, the odds of inadequate Pap tests were not
signicantly associated with partner violence (OR 1.18, 95%CI 0.99,
1.40).
Discussion
The present paper showed that for mid-aged women, partner
violence at least eight years earlier was associated with current
inadequate Pap testing. This nding contrasts with those of two
previous studies (Lemon et al., 2002; Taft et al., 2004). The age of the
women in the current study, which was focused on women in mid-
age, may account for some of these differences. One of the previous
studies was based on data collected from the Younger cohort of the
ALSWH, who were in their twenties; ndings indicated associations
between partner violence and increased Pap testing (Taft et al., 2004).
A smaller US study found younger women and women who had
experienced physical or sexual, rather than psychological partner
violence were more likely to report adequate Pap screening (Lemon et
al., 2002). Overall, the results suggest that relationships between
partner violence and Pap screening might be contingent upon the age
of the women concerned, with younger women more likely to have
adequate screening. Alternatively, this difference may represent a
temporal cohort effect.
It is possible that younger women might be more likely to
undertake Pap tests than mid-age women due to the associated need
to obtain contraceptives. However, this does not explain why women
who experience partner violence are more inclined in the case of
younger women, or less inclined in the case of mid-aged women, to
undergo Pap testing than other women in their age groups.
In our analysis, partner violence was associated with a range of
factors that have been shown to act as barriers to adequate cervical
cancer screening, including cohabitation, lower socio-economic
status, education, the presence of a chronic condition and depression
(Yelsma,1996; Coker et al., 2000; Wee et al., 2000; Savage and Clarke,
2001; Weinrab et al., 2002; Pirraglia et al., 2004; Ostbye et al., 2005). It
is possible that because women with a history of partner violence
were less likely to be cohabiting, they saw less need for routine Pap
testing. Yet, even when these factors were adjusted for in the
multivariable regression, the associations between partner violence
and inadequate Pap testing remained statistically signicant.
Cervical cancer screening is freely available in Australia. Therefore,
service cost and/or a lack of health insurance are not potential barriers
to screening, although associated costs (eg. travel) could interfere with
women's ability to take part in screening programs. Nevertheless,
while women who have experienced partner violence could be
adversely affected by associated costs, the association between
Table 1
Socio-demographic characteristics of women by experience of partner violence
between Survey 1 in 1996 and Survey 4 in 2004, Australia
Partner violence No partner violence
n=990 (%) n=6322 (%)
Area of residence
Urban 34.9 36.7
Rural 57.4 57.0
Remote 7.8 6.3
Highest educational qualication achieved
Less than higher school certicate 44.2 40.2
Higher school certicate 18.1 17.1
Trade/certicate/diploma 20.4 21.2
University degree 17.3 21.5
Difcult managing on income
Not 48.9 67.2
Sometimes 31.6 23.6
Always 19.5 9.2
Currently living with partner or spouse59.2 80.8
Percentages weighted to allow for over-sampling of women living in rural and remote
areas.
pb.05.
Table 2
Ever been in a violent relationship with partner/spouse in Survey 1, 1996 by health,
health service use and adequacy of screening in Survey 4, 2004, Australia
Characteristics in 2004 Partner
violence =
No partner
violence
n=990 (%) n=6322 (%)
Number of general practitioner visits in the last year
02 38.6 44.7
36 44.0 45.2
7 or more 17.4 10.1
Good access to GP of choice67.2 74.4
Any chronic physical condition15.3 8.5
Depressed (CESD1010)30.5 16.2
Blood pressure checked by a doctor 90.8 91.3
Cholesterol checked by a doctor 65.1 68.2
Regular Pap test (in the last 2 years)75.1 81.3
Percentages weighted to allow for over-sampling of women living in rural and remote
areas.
GP: general practitioner.
CESD10: 10 item Center for Epidemiological Studies Depression Scale.
pb.01.
Table 3
Odds ratios (OR) and 95% condence intervals (CI) for women who had experienced
partner violence at Survey 1 in 1996, of inadequatecervical cancer screening at Survey 4
in 2004, relative to women who had never experienced partner violence, Australia
Ever lived in a violent relationship
with a partner/spouse
n
Unadjusted OR (CI) 7306 1.42 (1.21; 1.66)
Adjusted OR (CI)
a
7035 1.20 (1.01; 1.42)
Adjusted OR (CI)
a
and preferred GP access 6978 1.18 (0.99; 1.40)
GP: general practitioner.
Of the 1422 women with inadequate screening in 2004, 243 had experienced partner
violence by 1996.
Of the 5884 women with adequate screening in 2004, 747 had experienced partner
violence by 1996.
Partner violence in 1996 was unknown for 6 women. Unadjusted OR = 243=747ðÞ
1179=5137ðÞ
=1:42
pb.05.
a
Adjusted for area of residence, education, difculty managing on income,
cohabitation status, number of GP visits, any chronic physical condition and depression.
186 D. Loxton et al. / Preventive Medicine 48 (2009) 184188
partner violence and inadequate screening remained signicant even
after adjustment for socio-economic status.
In Australia, cervical screening services are provided as part of
mainstream health services with general practitioners (GP) perform-
ing approximately 80% of Pap smears (Australian Institute of Health
and Welfare, 2008). The results clearly showed that women who had
experienced partner violence attended the GP more often than other
women. This is consistent with past research (Loxton et al., 2004), and
further demonstrates that service access is not a barrier to GP service
delivery. However, women who had experienced partner violence did
report poorer access to a GP of their choice. Furthermore, after
adjusting for the other socio-demographic and health factors, access
to a GP of choice had a small additional effect that reduced the odds
ratios for inadequate Pap smears among women who experienced
partner violence, relative to those who had not.
Interestingly, screening levels for blood pressure and cholesterol
were the same for women who had and those who had not
experienced partner violence, countering the argument that doctors
may not be encouraging screening (Harris, 2000). Taken together, the
results suggest that there is something about partner violence itself
that might be preventing mid-aged women from undertaking
screening for cervical cancer. In addition, it appears as though having
access to a GP of choice might act to mitigate the effect of partner
violence on cervical cancer screening.
Past research has indicated a strong association between partner
violence and sexual abuse (Campbell and Soeken, 1999) which might
affect the willingness of women to undergo procedures that can be
considered invasive. The results of the current study could be seen as
supporting this notion. Women who had experienced partner violence
were as likely to undergo non-invasive procedures, such as cholesterol
and blood pressure checks, as women who had not experienced
partner violence. However, these ndings require further investiga-
tions to determine the underlying mechanisms that explain the
associations between partner violence and inadequate cervical cancer
screening. A related issue concerns the relationship between the
patient and the GP. Access to a GP of choice infers that women feel
comfortable with their GP, which might encourage cervical cancer
screening. This could be of particular importance to women who have
lived with violent partners. However, the association was small and
requires further research.
The prevalence of partner violence in the current study is lower
than that found in the population of Australian women (Australian
Bureau of Statistics, 2006), although the age ranges are not directly
comparable between the two surveys. The single item that was used to
identify women who had experienced partner violence was likely to
lead to an under-estimate of partnerviolence prevalence (Robbe et al.,
1996). Another inuence was difculty contacting women who had
experienced partner violence. This was evident in the time between
the rst questionnaire in 1996 and the fourth questionnaire in 2004
and likely to be a reason for non-response at the initial mailout in
1996. Furthermore, the self-report measures used in this study might
also limit the ndings (Bowman et al., 1997; Canfell et al., 2006).
However, the study also has strengths. The use of a large representa-
tive community sample is rare in partner violence research, and the
longitudinal nature of the data adds further strength to the ndings.
Conclusion
The ndings show that partner violence could be a previously
unidentied barrier to preventive screening among mid-aged women.
Given that preventive screening for cancer is associated with
improved health outcomes (Gornick et al., 2004) and since partner
violence itself appears to be a risk factor for cervical cancer and late
stage diagnosis (Robbe et al., 1996; Modesitt et al., 2006; Loxton et al.,
2006), identifying ways of encouraging these women to undertake
regular screening is very important. Improved participation in cancer
screening has been found where women receive a letter of invitation,
educational material (Hewitt et al., 2002; Katz et al., 2007)and/or
telephone reminders (Dietrich et al., 2006). However, the efcacy of
these methods for encouraging women who have experienced partner
violence to undergo screening procedures is unknown. Further
research will be needed to determine the effectiveness of these
strategies for women who have experienced partner violence.
Conict of interest statement
All authors declare that there are no conicts of interest.
Acknowledgments
The research on which this paper is based was conducted as part of
the Australian Longitudinal Study on Women's Health, The University
of Newcastle and The University of Queensland. We are grateful to the
Australian Government Department of Health and Ageing for funding
and to the women who provided the survey data. We would like to
thank the two anonymous reviewers for their comments which
improved the quality of this paper.
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... IPV may influence cancer survivorship through delays in diagnosis or cancer treatment, reducing QOL [3] during treatment or recovery, and ultimately affect survival. While IPV may [15][16][17] or may not [18,19] be associated with receiving cancer screening at recommended intervals, IPV has been associated with not receiving follow-up care for pre-invasive disease [20] and with delays in receipt of care for invasive cancer [21]. IPV may impact women's ability to obtain cancer treatment because those currently experiencing IPV are less likely to have health insurance, are more likely to live in poverty, and have fewer transportation options [13,22]. ...
... The emerging literature to describe the effect of IPV on receipt of cancer screening deserves mention here because screening reduces the risk of being diagnosed at a later cancer stage if positive screening results in appropriate follow-up. Findings from several such studies have been mixed [15][16][17][18][19] and suggest that IPV may not affect mammographic screening yet women experiencing IPV may be less likely to receive cervical cancer screening at recommended intervals [18]. Differences in socioeconomic status and access to health care of women at risk of cervical relative to breast cancer may explain these observed differences cancer screening patterns. ...
Article
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PurposeBecause intimate partner violence (IPV) may disproportionately impact women’s quality of life (QOL) when undergoing cancer treatment, women experiencing IPV were hypothesized to have (a) more symptoms of depression or stress and (b) lower QOL as measured with the Functional Assessment of Cancer Therapy (FACT-B) and Functional Assessment of Chronic Illness Therapy—Spiritual Well-being (FACIT-SP) Scales relative to those never experiencing IPV. Methods Women, aged 18–79, who were included in one of two state cancer registries from 2009 to 2015 with a recent incident, primary, invasive biopsy-confirmed cancer diagnosis were recruited and asked to complete a phone interview, within 12 months of diagnosis. This interview measured IPV by timing (current and past) and type (physical, sexual, psychological), socio-demographics, and health status. Cancer registries provided consenting women’s cancer stage, site, date of diagnosis, and age. ResultsIn this large cohort of 3,278 women who completed a phone interview, 1,221 (37.3%) disclosed lifetime IPV (10.6% sexual, 24.5% physical, and 33.6% psychological IPV). Experiencing IPV (particularly current IPV) was associated with poorer cancer-related QOL defined as having more symptoms of depression and stress after cancer diagnosis and lower FACIT-SP and FACT scores than women not experiencing IPV and controlling for confounders including demographic factors, cancer stage, site, and number of comorbid conditions. Current IPV was more strongly associated with poorer QOL. When compared with those experiencing past IPV (and no IPV), women with cancer who experienced current IPV had significantly higher depression and stress symptoms scores and lower FACIT-SP and FACT-G scores indicating poorer QOL for all domains. While IPV was not associated with being diagnosed at a later cancer stage, current IPV was significantly associated with having more than one comorbid physical conditions at interview (adjusted rate ratio = 1.35; 95% confidence interval 1.19–1.54) and particularly for women diagnosed with cancer when <55 years of age. Conclusions Current and past IPV were associated with poorer mental and physical health functioning among women recently diagnosed with cancer. Including clinical IPV screening may improve women’s cancer-related QOL.
... Likewise, a population-based study with Australian women did not find any significant association between violence against women and cervical cancer screening (OR = 1.18; 95%CI 0.99-1.40) 24 . The associations were close to the significance threshold in the last two studies. ...
Article
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Objective: To analyze the association between intimate partner violence and not performing the cytopathologic test in the last three years. Methods: It is a transversal study, performed in 26 health units in the city of Vitória, state Espírito Santo, from march to September 2014. The sample was constituted by 106 primary care female users, aging from 30 to 59 years-old. Data on cervical cancer screening were collected, besides the women's sociodemographic, behavior, obstetric, and gynecological characteristics by an interview, and the World Health Organization recommended tool for identifying violence experiences was applied. The analysis was performed through the chi-square test for association, linear trend for ordinal variables, and the Poisson regression analysis with robust variance. Results: Among the participating women, 14% (95%CI 12.0-17.2) had overdue Pap tests. Most women who did not perform the test had lower schooling levels, lower income, were smokers, in an unmarried union, having had their sexual debut before 15 years-old, three or more pregnancies, and two or more partners in the last 12 months. Women who suffered intimate partner sexual and physical violence were, respectively, 1.64 (95%CI -1.03-2.62) and 1.94 (95%CI 1.28-2.93) times more delayed in the Pap tests than non-victims. Conclusions: Violence is a significant exacerbating factor and affects women's health negatively. Women who are physically or sexually victimized by their partners are more vulnerable to not performing Pap tests and, consequently, have fewer chances of early diagnosing cervical cancer.
... 8 Durante los últimos 25 años se han presentado oficialmente en México más de 100 000 muertes por Recomendaciones para la definición de la política de vacunación contra el virus del papiloma en México Comité asesor externo para la definición de la política de vacunación contra el virus del papiloma en México* *Eduardo Lazcano-Ponce, (1) Jorge Salmerón-Castro, (2) Alejandro García-Carrancá, (3,4) Carlos Aranda-Flores, (5) Vicente Madrid-Marina, (1) César Misael Gómez-Altamirano, (6) Olga Georgina Martínez-Montañez. (7) ( cáncer cervical, y a partir de 2006 se constituyó en la segunda causa de muerte por tumores malignos en la mujer, después del cáncer de mama. A pesar de que existe una disminución significativa de la mortalidad por cáncer cervical a partir de la década de los noventa, en gran medida atribuible a la disminución de las tasas de natalidad, 9 persiste en México un elevado incremento en el número de casos por cáncer cervical en áreas rurales, a lo que hay que dar una respuesta de prevención y control inmediata. ...
Article
Background: Sexual assault affects one in three US women and may have lifelong consequences for women's health, including potential barriers to completing cervical cancer screening and more than twofold higher cervical cancer risk. The objective of this study was to determine whether a history of sexual assault is associated with reduced cervical cancer screening completion among women Veterans. Materials and Methods: We analyzed data from a 2015 survey of women Veterans who use primary care or women's health services at 12 Veterans Health Administration facilities (VA's) in nine states. We linked survey responses with VA electronic health record data and used logistic regression to examine the association of lifetime sexual assault with cervical cancer screening completion within a guideline-concordant interval. Results: The sample included 1049 women, of whom 616 (58.7%) reported lifetime sexual assault. Women with a history of sexual assault were more likely to report a high level of distress related to pelvic examinations, and to report ever delaying a gynecologic examination due to distress. However, in the final adjusted model, lifetime sexual assault was not significantly associated with reduced odds of cervical cancer screening completion (OR 1.35, 95% CI 0.93-1.97). Conclusions: Contrary to our expectations, sexual assault was not significantly associated with gaps in cervical cancer screening completion. Three- to five-year screening intervals may provide sufficient time to complete screening, despite barriers. Trauma-sensitive care practices promoted in the VA may allow women to overcome the distress and discomfort of pelvic examinations to complete needed screening. ClinicalTrials.gov (#NCT02039856).
Article
Objective: Childhood exposure to intimate partner violence (IPV) is a pervasive public health epidemic with profound impact on child health. While past work has demonstrated how abusive partners exert control over IPV survivors in a variety of settings (e.g. workplace, courts, home), scant research has examined how IPV power and control behaviors manifest themselves in pediatric healthcare settings. In this study, we explore the perspectives of pediatric IPV experts about: 1) behaviors used by abusive partners to control IPV survivors in pediatric healthcare settings; 2) how controlling behaviors impact healthcare access and quality; and 3) recommendations for the pediatric healthcare team. Methods: Individual semi-structured interviews were conducted with pediatric IPV experts recruited through snowball sampling. Interviews were individually coded by two research team members and analyzed using thematic analysis. Results: Twenty-eight pediatric IPV experts participated. Participants described several types of controlling behaviors including limiting healthcare access, dominating conversations during medical visits, controlling medical decision making, and manipulating perceptions of the healthcare team. Participants acknowledged the challenges of recognizing controlling behaviors and provided several recommendations to addressing behaviors such as leveraging the expertise of multidisciplinary teams. Conclusions: Participants described how abusive partners may attempt to control or discredit their partners in pediatric healthcare settings, using subtle behaviors that may be easily missed by the healthcare team. These results set the stage for further research and clinical practice innovation including triangulating the findings with IPV survivors, examining how frequently these behaviors occur, and developing multidisciplinary IPV training for the pediatric healthcare team.
Article
Issue addressed: Australia's national cervical screening program has reduced rates of cervical cancer morbidity and mortality. However, these benefits have not been experienced by all women. A Cervical Cancer Screening Project was implemented with lay health educators to address inequitable screening access by women experiencing socioeconomic disadvantage. Methods: Resources and a training program were developed and piloted with the specialist homelessness services workforce in Sydney, NSW. Data was collected to inform their development and evaluation through interviews, focus groups, self-administered surveys, and analysis of NSW Pap Test Register data. Results: Women reported low familiarity with the term 'cervical screening'. They identified a good patient-doctor relationship, and seeing a female practitioner, as screening enablers. Whilst the majority reported having cervical screening before, NSW Pap Test Register data showed only 74% had screened previously and of those, 69% were overdue. Homelessness service workers expressed interest in talking with clients about cervical screening, and reported increased knowledge and confidence following training. Conclusion: The homelessness sector is an appropriate venue to access women who are disadvantaged and under-screened. However, increasing workforce capacity to discuss screening does not lead to increased screening for women accessing these services, therefore further efforts are required. SO WHAT?: Access to cervical screening by women experiencing disadvantage remains a challenge. Sustained multi-faceted health promotion efforts are required to increase access. These should be informed by additional research exploring barriers and enablers for these women.
Article
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The purpose of this project was to assess the magnitude of the relationship between violence against women and cancer; to identify the exposures and cancers for which this relationship was particularly robust; to identify the effect of violence exposure on cancer screening. We conducted a meta-analysis of 36 studies to determine the relationship between violence against women and cancer outcomes, including screening, in 2017. Results from this review provide evidence of a significant, positive relationship between violence and cancer diagnoses, particularly for cervical cancer. Women who were victims of intimate partner violence and sexual abuse were more likely to be diagnosed with cancer compared with non-victims. Violence against women did not appear to be related to cancer screening practices and routine clinical service utilization; however, violence was associated with greater odds of abnormal pap test results. Victims of intimate partner violence and women who suffered physical abuse were more likely to have abnormal pap test results. In conclusion, use of screening tools for violence against women in clinical settings may improve the breadth and quality of research on violence against women and cancer. Investigators should consider how to creatively apply case-control and retrospective cohort designs to investigate the complex mechanisms and moderators of the relationship between violence against women and cancer.
Article
Woman to Woman (W2W) is a novel adaptation of the Sisters Informing Sisters about Topics on AIDS (SISTA) HIV prevention program. This article describes the process of adapting and piloting W2W based on recommendations from existing HIV prevention research. Six older women, all of whom had histories of homelessness and the majority of whom identified as African American, enrolled in the study, which piloted the adapted intervention and materials, evaluated the acceptability of the program, and assessed the measures related to the intervention. Participants described satisfaction with the program and had high rates of attendance; observations regarding the measures suggest the need to further develop assessments of HIV knowledge, condom use self-efficacy, and risk behaviors in this context.
Article
Aims and objectives: To present a systematic review of papers published on the relationship between violence against women and cervical cancer screening. Background: Violence against women is a serious public health problem. This phenomenon can have negative effects on victims' health and affect the frequency at which they receive cervical cancer screening. Design: A systematic literature review. Methods: This study was carried out in October 2015 with searches of the Lilacs, PubMed and Web of Science databases using the following keywords: violence, domestic violence, battered women, spouse abuse, Papanicolaou test, vaginal smears, early detection of cancer and cervix uteri. Results: Eight papers published between 2002-2013 were included in this review, most of which were cross-sectional studies. Three studies found no association between victimisation and receiving Pap testing, and five studies reported an association. These contradictory results were due to higher or lower examination frequencies among the women who had experienced violence. Conclusion: The results of this study indicate that the association between violence against women and cervical cancer screening remains inconclusive, and they demonstrate the need for more detailed studies to help clarify this relationship. Relevance to clinical practice: Professionals who aid women should be knowledgeable regarding the perception and detection of violence so that they can interrupt the cycle of aggression, which has harmful impacts on victims' health.
Article
Full-text available
Objectives: Partner violence affects one in three women worldwide and is linked to higher rates of women’s cancers with increased utilization of health care services. However, evidence of the association between severity of violence and health screening behaviors (i.e., Pap testing, mammography, & clinical/self-breast exams [SBEs]) is scant. The purpose of this study was to identify engagement of abused women in preventive health screening behaviors. Materials and Methods: This was a cross-sectional study of 284 abused women with children. Participants were part of a 7-year prospective study to examine the treatment efficacy of the 2 models most often offered to abused women. At the 24th month interview, data on health promotion behaviors were collected via investigator designed instrument. Both descriptive and chi square analysis were used for data analysis. Results: Abused women were more likely to engage in preventative health behaviors than the general US female population but had a higher incidence of sexually transmitted infections (STIs) and abnormal Pap test results with variance based on race, ethnicity, immigration status, language, and the type of intimate partner violence (IPV) services initiated. Preventative screening was adequate, but there was poor follow-up care for abused women who received abnormal results. Conclusion: Findings suggest urgent need to maintain high rates of screening and initiate better follow-up care. Recognition of the potential co-existence of gynecological infections or cervical cellular irregularities with the experience of partner abuse may lead health care providers to improved diagnosis and treatment for both IPV and abnormal gender-specific health care outcomes.
Article
from 0.60 to 0.58 with usual care; the proportion who had Papanicolaou testing increased from 0.71 to 0.78 with the intervention and was unchanged with usual care; and the proportion who had colorectal screening increased from 0.39 to 0.63 with the intervention and from 0.39 to 0.50 with usual care. The difference in the change in screening rates between groups was 0.12 for mammography (95% CI, 0.06 to 0.19), 0.07 for Papanicolaou testing (CI, 0.01 to 0.12), and 0.13 for colorectal screening (CI, 0.07 to 0.19). The proportion of women who were up to date for 3 tests increased from 0.21 to 0.43 with the intervention. Limitations: Participants were from 1 city and had access to a regular source of care. Medical records may not have captured all cancer screenings. Conclusions: Telephone support can improve cancer screening rates among women who visit community and migrant health centers. The intervention seems to be well suited to health plans, large medical groups, and other organizations that seek to increase cancer screening rates and to address disparities in care.
Article
Background: Compared with thinner women, obese women have higher mortality rates for breast and cervical cancer. In addition, obesity leads to adverse social and psychological consequences. Whether obesity limits access to screening for breast and cervical cancer is unclear. Objective: To examine the relation between obesity and screening with Papanicolaou (Pap) smears and mammography. Design: Population-based survey. Setting: United States. Participants: 11 435 women who responded to the Year 2000 Supplement of the 1994 National Health Interview Survey. Measurements: Screening with Pap smears and mammography was assessed by questionnaire. Results: In women 18 to 75 years of age who had not previously undergone hysterectomy (n = 8394), fewer overweight women (78%) and obese women (78%) than normal-weight women (84%) had had Pap smears in the previous 3 years (P < 0.001). After adjustment for sociodemographic information, insurance and access to care, illness burden, and provider specialty, rate differences for screening with Pap smears were still seen among overweight (-3.5% [95% Cl, -5.9% to -1.1%]) and obese women (-5.3% [Cl, -8.0% to -2.6%]). In women 50 to 75 years of age (n = 3502), fewer overweight women (64%) and obese women (62%) than normal-weight women (68%) had had mammography in the previous 2 years (P < 0.002). After adjustment, rate differences were -2.8% (Cl, -6.7% to 0.9%) for overweight women and -5.4% (Cl, -10.8% to -0.1%) for obese women. Conclusions: Overweight and obese women were less likely to be screened for cervical and breast cancer with Pap smears and mammography, even after adjustment for other known barriers to care. Because overweight and obese women have higher mortality rates for cervical and breast cancer, they should be targeted for increased screening.
Article
. Objectives : To determine the prevalence of domestic violence among female patients and to identify clinical characteristics that are associated with current domestic violence. . Design : Cross-sectional, self-administered, anonymous survey. . Setting : 4 community-based, primary care internal medicine practices. . Patients : 1952 female patients of varied age and marital, educational, and economic status who were seen from February to July 1993. . Measurements : The survey instrument included previously validated questions on physical and sexual abuse, alcohol abuse, and emotional status and questions on demographic characteristics, physical symptoms, use of street drugs and prescribed medications, and medical and psychiatric history. . Results : 108 of the 1952 respondents (5.5%) had experienced domestic violence in the year before presentation. Four hundred eighteen (21.4%) had experienced domestic violence sometime in their adult lives, 429 (22.0%) before age 18 years, and 639 (32.7%) as either an adult or child. Compared with women who had not recently experienced domestic violence, currently abused patients were more likely to be younger than 35 years of age (prevalence ratio [PR], 4.1 [95% CI, 2.8 to 6.0]) ; were more likely to be single, separated, or divorced (PR, 2.5 [CI, 1.7 to 3.6]) ; were more likely to be receiving medical assistance or to have no insurance (PR, 4.3 [CI, 2.8 to 6.6]) ; had more physical symptoms (mean, 7.3 ± 0.38 compared with 4.6 ± 0.08 ; P < 0.001) ; had higher scores on instruments for depression, anxiety, somatization, and interpersonal sensitivity (low self-esteem) (P < 0.001) ; were more likely to have a partner abusing drugs or alcohol (PR, 6.3 [CI, 4.4 to 9.2]) ; were more likely to be abusing drugs (PR, 4.4 [CI, 1.9 to 10.4]) or alcohol (PR, 3.1 [CI, 1.5 to 6.5]) ; and were more likely to have attempted suicide (PR, 4.3 [CI, 2.8 to 6.5]). They visited the emergency department more frequently (PR, 1.7 [CI, 1.2 to 2.5]) but d
Article
Affective orientations of 79 perpetrators, 57 victims, and 70 functional spouses were examined. Self-report measures were utilized to assess five affective orientations: (a) alexithymia, (b) affective orientation, (c) range of positive feelings, and (d) expression of positive affect, and (e) expression of negative affect. Perpetrators were significantly more alexithymic than functional spouses but were not significantly different from victims. Perpetrators and victims report being less disposed to possess or express their feelings than do functional males and females. Male perpetrators were significantly less aware of their affective states than functional males; and female victims were significantly less aware of their affective states than functional females. Female victims possessed significantly fewer positive feelings than functional women. Expression of positive emotions was significantly less for female victims than for functional females. Deficit of positive affect versus the presence of negative affect was a significant indicator of physical abuse reported within intimate relationships.
Article
Using data from a telephone survey of 8,000 U.S. men and 8,000 U.S. women, this study compares the prevalence and consequences of violence perpetrated against men and women by marital and opposite-sex cohabiting partners. The study found that married/cohabiting women reported significantly more intimate perpetrated rape, physical assault, and stalking than did married/cohabiting men, whether the time period considered was the respondent's lifetime or the 12 months preceding the survey. Women also reported more frequent and longer lasting victimization, fear of bodily injury, time lost from work, injuries, and use of medical, mental health, and justice system services.
Article
A volunteer community sample of 159 primarily (77%) African American battered women were interviewed about forced sex by their partner (or ex-partner). Almost half (45.9%) of the sample had been sexually assaulted as well as physically abused. Except for ethnicity, there were no demographic differences between those who were forced into sex and those who were not, and there was no difference in history of child sexual abuse. However, those who were sexually assaulted had higher scores on negative health symptoms, gynecological symptoms, and risk factors for homicide even when controlling for physical abuse and demographic variables. The number of sexual assaults (childhood, rape, and intimate partner) was significantly correlated with depression and body image.
Article
Background: Minority and low-income women receive fewer cancer screenings than other women. Objective: To evaluate the effect of a telephone support intervention to increase rates of breast, cervical and colorectal cancer screening among minority and low-income women. Design: Randomized, controlled trial conducted between November 2001 and April 2004. Setting: 11 community and migrant health centers in New York city. Patients: 1413 women who were overdue for cancer screening. Intervention: Over 18 months, women assigned to the intervention group received an average of 4 calls from prevention care managers and women assigned to the control group received usual care. Follow-up data were available for 99% of women, and 91 % of the intervention group received at least 1 call. Measurements: Medical record documentation of mammography, Papanicolaou testing, and colorectal cancer screening according to U.S. Preventive Services Task Force recommendations. Results: The proportion of women who had mammography increased from 0.58 to 0.68 with the intervention and decreased from 0.60 to 0.58 with usual care; the proportion who had Papanicolaou testing increased from 0.71 to 0.78 with the intervention and was unchanged with usual care; and the proportion who had colorectal screening increased from 0.39 to 0.63 with the intervention and from 0.39 to 0.50 with usual care. The difference in the change in screening rates between groups was 0.12 for mammography (95% Cl, 0.06 to 0.19), 0.07 for Papanicolaou testing (Cl, 0.01 to 0.12), and 0.13 for colorectal screening (Cl, 0.07 to 0.19). The proportion of women who were up to date for 3 tests increased from 0.21 to 0.43 with the intervention. Limitations: Participants were from 1 city and had access to a regular source of care. Medical records may not have captured all cancer screenings. Conclusions: Telephone support can improve cancer screening rates among women who visit community and migrant health centers. The intervention seems to be well suited to health plans, large medical groups, and other organizations that seek to increase cancer screening rates and to address disparities in care.
Article
OBJECTIVE: Our purpose was to examine, in women aged 18 to 49, the relationship of violent experiences (child abuse, violent crime, spouse abuse) to gynecologic problems. STUDY DESIGN: Data from 1599 participants in a randomized, sociodemographically representative telephone survey of U.S. women were used. Gynecologic problems were measured by self-report of receiving a physician's diagnosis of severe menstrual problems, a sexually transmitted disease, or a urinary tract infection. Statistical analyses used were the χ2 test and multiple logistic regression. RESULTS: A total of 31.5% of participants reported a diagnosis of gynecologic problems in the past 5 years. Those with problems were more likely to report childhood abuse, violent crime victimization, and spouse abuse. In logistic regression models controlling for sociodemographic factors and access to medical care, violence events remained significantly associated with gynecologic problems. CONCLUSIONS: A history of gynecologic problems may indicate that a patient has been harmed by violence. However, all women are at risk of being harmed by violence, and a violence history should be obtained as part of the intake protocol for all patients. Physicians need to be prepared to provide information about local community services, including counseling, domestic violence centers, shelters, and advocacy groups. (AM J OBSTET GYNECOL 1996;174:903-7.)
Article
To investigate the factors associated with the use of screening mammography for breast cancer and cervical smear tests for cervical cancer, a theoretical framework was used comprising elements from the Health Belief Model, the Theory of Reasoned Action, and illness representations from the self-regulatory model. Items reflecting older women’s illness representations about cancer and cancer screening were derived from an earlier qualitative study. Using a highly structured interview schedule, telephone interviews were conducted with 1,200 women aged 50-70 years. There were considerable similarities between the factors associated with both mammography and cervical smear test behaviours. The factors associated with screening mammography behaviour were: perceived barriers, perceived benefits, social influence, the illness representations, and marital status. The factors associated with cervical smear test behaviour were: perceived barriers, perceived benefits, emotions as a cause of cancer, feeling frightened of cancer, the illness representations, having a usual general practitioner, and being younger.
Derived and tested a short form of the Center for Epidemiologic Studies Depression Scale (CES-D) for reliability and validity among 1,206 well older adults (aged 65–98 yrs). The 10-item screening questionnaire, the CESD-10, showed good predictive accuracy when compared to the full-length 20-item version of the CES-D. The CESD-10 showed an expected positive correlation with poorer health status scores and a strong negative correlation with positive affect. Retest correlations for the CESD-10 were comparable to those in other studies. The CESD-10 was administered again after 12 mo. Data were based on 80% of the original sample. Scores were stable with strong correlation. (PsycINFO Database Record (c) 2012 APA, all rights reserved)